Group B Strep and Home Birth

Women who have tested positive for Group B Streptococcus (GBS) in pregnancy are often told that their only option is to have a hospital birth, with intravenous antibiotics given to them during labour. There are, of course, other options; you may feel, after researching the subject, that intravenous antibiotics are not necessary, or that you would want to have them in certain situations, but not all. You may also be able to arrange to have intravenous antibiotics administered at a home birth. There are many women who have had home births despite being carriers of Group B Strep; the aim of this article is to help you make your own choice.

Group B Streptococcus (usually abbreviated to GBS; also known as 'haemolytic Strep' or 'Beta Strep') is a bacteria which many women carry in the vagina with no symptoms at all, while for others it can cause infections in the uterus or the urinary tract. It is thought that 10-30% of women in the UK carry GBS in the vagina.

As women in the UK are
not normally screened for GBS routinely in pregnancy, the vast majority of
women who carry GBS during pregnancy and birth will never know about it,
their labours will not be managed any differently, and they and their babies
will be none the worse off.

If the mother's vagina is colonized with Group B Strep, her baby's skin may pick it up from the birth canal during labour. But just having a positive skin test for GBS does not mean that your baby is unhealthy - it is normal in this situation and for the vast majority of babies, it will not cause any problems at all. However, in a small minority of babies the bacteria can go on to cause an infection, and these babies develop Group B Strep Disease, more technically termed Early Neonatal Group B Streptococcal Septicaemia (ENGBSS), where the GBS infection causes blood poisoning. This can lead to meningitis and disability or death.

GBS disease is very rare - in the UK, if the mother is known to carry GBS when she is in labour, there is a 35-50% chance that her baby will pick up GBS on its skin, but only 0.2-0.5% of these babies will become ill as a result. Putting these figures together, if a woman who is carrying GBS in labour has a 50% chance that her baby will pick up the bacteria, the chance of the baby developing GBS disease is between 1 in 400 and 1 in 1,000.

The source for these statistics is the Royal College of Obstetricians and Gynaecologists guidelines on GBS. Note that rates for GBS disease in newborns are higher in the USA than in the UK, which is why you may read of higher infection rates in other articles online. We do not know why this is, but one guess is it may be because of differences in routine maternity care between the UK and the USA, eg more internal exams pushing the bacteria upwards from the lower vagina towards the uterus while in active labour, or more common use of fetal scalp electrodes in the USA.

These figures are for the average risk faced by all women carrying GBS in labour. They do not tell the whole story, because some women are at far higher risk of having a baby affected by GBS disease than others. Babies who fall into certain groups have a higher risk of developing the disease:

Preterm babies (especially before 35 weeks, but also before 37 weeks. One recent UK study
of risk factors found that 6 babies out of more than 62,000 born in the
study period died of GBS infection; of these, 5 were born before 36 weeks
(see ref 3).

If a woman who falls into the high-risk categories for GBS, as described above, is given intravenous antibiotics ('IV antibiotics') when she is in labour, the chance of her baby contracting GBS disease is reduced by 60%, and the chance of the baby dying from GBS disease is reduced by 95%. Taking antibiotics before labour - whether oral or
intravenous - does not seem to make much difference, which is why the
emphasis is on IV antibiotics in labour. Note that having IV antibiotics does not mean that you will be on a drip thoughout your labour. Midwife Denise Ellis writes: "In most hospitals IV antibiotics are administered via a venflon and given as a bolus dose (administered directly into the vein via a venflon - which takes minutes) and means there is no drip."

The availability of IV antibiotics in labour is a modern miracle which has undoubtedly saved the lives of many babies. But, like many other obstetric life-savers, this intervention carries risks as well as potential benefits. The balance of risks and benefits will be different for each family, and as with any offer of medical treatment, it is up to you as an individual to decide whether to accept it.

Mother may have an allergic reaction to antibiotics, up to and including anaphylactic shock, which can be fatal. 1 in 10,000 women receiving antibiotics for GBS can be expected to go into anaphylactic shock, and 1 in 10 so affected will die (ref: RCOG paper on GBS).

Baby may become more at risk of infection from other, antibiotic-resistant organisms

The RCOG paper on GBS states:

"Antenatal screening and treatment have not yet demonstrated an effect on all cause neonatal mortality, and may carry disadvantages for the mother and baby. These include potentially fatal anaphylaxis, the medicalisation of labour and the neonatal period, and infection with resistant organisms." (Page 1, Section 2)

Although it seems that most UK hospitals recommend that women have IV antibiotics during labour if they test positive for GBS antenatally, in fact the RCOG recommendation is just that antibiotics be 'considered' in this situation, and that the risks are balanced against any possible benefit of IV antibiotics in labour.

Waterbirth?

Some hospitals have policies that women who have tested positive for GBS should not be 'allowed' to have a waterbirth, but the Group B Strep Support Society says that there is no reason why not (see GBSS FAQs). They reproduce a paper from Practising Midwife - Waterbirth for women with GBS - a pipe dream? by Plumb, Holwell, Burton and Steer.

I have not found any good reason to ban waterbirth when the mother is simply GBS positive, without any other risk factors. The rationale is sometimes that the unit likes to use continuous electronic fetal monitoring where the mother has tested positive for GBS, but again, this does not seem to be supported by the evidence if there are no other risk factors. If you are planning to use a birth pool at home, that is your decision, of course, and it may be easier to arrange than a waterbirth in hospital.

Home birth is still an option after a positive GBS result. You can have a home birth with, or without, intravenous antibiotics. If you are booking with independent midwives then they will probably be very familiar with the condition. If you are planning a home birth on the NHS then you may have to be prepared to state your case clearly and firmly; remember that it is your decision. You may find that it helps to have relevant research and articles available to discuss with your midwives.

Can you have IV antibiotics at home? Is there anything else to try?

Most UK hospitals do not offer the option of having intravenous antibiotics at a home birth, because of concerns about the mother having a severe allergic reaction. However, there are certainly some midwife teams which are prepared to administer antibiotics at home - eg see Judith G's birth story. If you think that this is the right choice for you, it may be worth writing to the Supervisor of Midwives at your hospital to request that you be given intravenous antibiotics at home.

Another option is to go to hospital in early labour and have a dose of intravenous antibiotics there, and then return home to continue with your labour. It may take some arranging, but it can be done - see Kate Simpson's birth story, and also Lucy B. However, be aware that once in hospital, there may be great pressure on you to remain there, and you may not feel like moving. See 'Accidental Hospital Birth' for cases where this has happened. Therefore, if you are considering doing this, you may want to make a birthplan focussed on a hospital birth as well as one for a homebirth. You could also research the hospital's policies regarding babies born to GBS positive mothers, and consider whether you are happy with them - it may be difficult to assert yourself, or research the issues, once you are in hospital.

Intramuscular antibiotic injections

There is another option for people who want antibiotics but whose
hospitals will not provide them IV in labour at home. It's
intramuscular injections in the last weeks of pregnancy, and is suggested as an option by the Group B Strep Support Society; it may be worth discussing with your GP, particularly if your obstetrician will not consider any alterntive to IV antibiotics in hospital.

GBSS website's FAQ about homebirth with
GBS:

Our medical advisory panel's recommendations for stopping GBS
infections in newborn babies are the same for home births as for
hospital births - women whose babies are at higher risk of developing
GBS infection should be offered intravenous antibiotics from the start
of labour until delivery.

Home births are becoming increasingly popular and, if you want a home
birth with intravenous antibiotics during labour until delivery, it
may be possible for your midwife to give you intravenous antibiotics
prescribed for you by your GP. This is not widely available. Some
areas won't permit intravenous antibiotics to be given at home - there
is a small risk that you would get a severe allergic reaction to the
antibiotics (see What are the potential risks of antibiotics? above)
and, obviously, there is no intensive care unit nearby. The risk is
small but your health professionals may be anxious. Of course, around
25% of women having home births probably carry GBS in their vagina at
delivery without knowing it. This issue needs to be discussed with
your medical team.

Oral antibiotics are not recommended for women for GBS carriage during
pregnancy or labour – quite simply, there's no evidence that they
prevent GBS infections in babies. If you have set your heart on a home
birth, you may wish to consider having intramuscular antibiotics as
outlined in "I'm worried I won't get 4+ hours of IV antibiotics before
my baby is born" above, though our medical advisory panel do not
recommend them in lieu of intravenous antibiotics during labour, but
they may be better than nothing if that really is the only
alternative.

===

Q: I'm worried I won't get 4+ hours of IV antibiotics before my baby is born.

A very small study1 showed giving intramuscular penicillin eradicated
GBS colonisation for at least 6 weeks in 75% of women known to carry
GBS. So far, this very small study (50 of 78 women received
intramuscular antibiotics) has not been repeated, so it is difficult
to give advice based upon this data.

For women known to carry GBS where it is not expected that the
intravenous antibiotics can be given for at least 4 hours before
delivery, an intramuscular injection of 4.8 MU (2.9 g) of Penicillin G
at about 35 weeks of pregnancy may be useful in addition to
intravenous antibiotics given from the onset of labour or membranes
rupturing until delivery to try to eradicate GBS colonisation until
after delivery.

Regardless of whether you have intramuscular antibiotics to try to
eradicate GBS colonisation, it is recommended that all women in higher
risk categories be offered intravenous antibiotics from the onset of
labour or waters breaking, plus at 4 hourly intervals until delivery.

There are downsides of intramuscular penicillin - the injection is
painful, there is a small risk of an allergic reaction and of
antibiotic resistance developing (see below). These risks are repeated
with the intravenous antibiotics given in labour.

For intramuscular antibiotics, there are no known alternatives to
penicillin for penicillin-allergic women.

Alternative remedies

There are various 'alternative' remedies which may be tried to eliminate GBS colonisation, but there is no real evidence that they are likely to be effective long-term. Some have had success using cloves of garlic in the vagina, but many have also found that as soon as they stop using the garlic, or despite it, they still test positive for GBS. Of course, there may be the potential for 'alternative' remedies to disrupt the normal bacterial balance in the vagina, and 'normal' skin colonisation of the newborn with beneficial bacteria, just as antibiotics do. For many ideas on DIY therapies, see the
Gentlebirth.org GBS section.

Chlorhexidine (Hibiscrub or Hibiclens) vaginal wash

This is certainly not a 'complementary' therapy, but it is one you can do at home. Chlorhexidine (often seen as Hibiscrub wash in the UK): douching with this antibacterial disinfectant during labour has been shown to greatly reduce the risk of GBS transmission in some trials. Numbers studied have not been large enough to see a reduction in overall illness rates, but this may be a reflection on the small number of trials conducted, rather than on the effectiveness of the treatment.

Adverse reactions to Hibiscrub are, apparently, rare and
minor - it doesn't contribute to antibiotic resistance and appears not
to wipe out Lactobacillus in some studies, although of course we don't know the long-run impact of interfering with normal newborn skin colonisation. But as an alternative to antibiotics, this approach is arguably less invasive. It has the great bonus that it can be done at any time in labour, as the idea is to wipe out GBS locally in the vagina, not throughout your body - so if IV antibiotics have been given but haven't had the 4 hours they need to work, Chlorhexidine can be used as a fallback option.

Cochrane report (full) - says there is not enough evidence to recommend it
as some studies have been poor quality. Moreoever, in developed countries where the vast majority of births occur in hospital, IV antibiotics in labour are known to provide good protection against GBS disease, so there is perhaps little incentive to explore other options.

In 2009 The Lancet published a study which found that Chlorhexidine
wipes used on the vagina and the baby were not effective against
GBS, but presumably this would not be as thorough as a douche. I have
not seen the full text of the article but the Medscape report seems to
suggest that it may have been only an external, vulval wipe - I can't
see how using a wipe internally would really work.http://www.medscape.com/viewarticle/711166

The US Midwife Archives at gentlebirth.org have a useful section on
how midwives use this approach:
http://www.gentlebirth.org/archives/gbs.html#Lavage . There is a great variation in practise, with some using the wash internally, and others simply externally. As GBS colonises the lower part of the vagina, I cannot see how merely washing externally could work.

Arranging a homebirth when GBS positive

GBS became an issue for me when I was expecting my fourth baby, and discovered that a swab, taken by my GP a few months before I became pregnant, was positive for GBS.

Here is a copy of the letter I sent my midwife team. The team agreed to support the plan of action I proposed, but in the event my repeat test at 36 weeks did not find any GBS infection. For details of the most reliable test for GBS, please see the UK Group B Strep Support group website.

Dear X,

I've just been to see my GP and we checked through my notes to see what the situation was regarding Group B Streptococcus.... a swab in September 2003 found moderate presence of GBS, but nothing else ...

I've been reviewing the RCOG's latest clinical guidelines for GBS (see below, copy enclosed in case you don't have one to hand) and have looked at the section on GBS in 'A Guide To Effective Care in Pregnancy and Childbirth' by Enkin, Keirse et al.

It looks to me as if an incidental finding of GBS colonization before the current pregnancy is not of huge significance at the moment, and that I would need to have another swab taken at 35-37 weeks to see if there is likely to be any colonization when I actually go into labour. The RCOG do not, for instance, recommend that antibiotics are given in labour to a woman who has just had GBS colonization detected in a previous pregnancy (see section 9.3), and I suppose that this is most similar to my situation.

Where a woman has GBS colonization in late pregnancy but has no other risk factors such as prolonged ROM in labour, preterm labour, fever in labour, GBS in urine, etc., the RCOG recommendations are just that intrapartum antibiotics should be 'considered' (section 9.2) but they are not strongly advised or recommended explicitly.

In the absence of any of these other risk factors, and if a woman does not take intrapartum antibiotics, the chances of the baby having GBS disease to any extent, even mildly, is about 1 in 500, and the risk of it dying is less than 1 in 10,000, if my maths is correct. It does not seem to be clear that taking antibiotics in labour in such a situation makes any appreciable difference to cases of severe neonatal infection.

I would not want to take antibiotics in labour without very good reason. Quite apart from making the whole process more complicated (and making me feel ill, as antibiotics usually do), it seems that it could increase some other risks to my baby. There is quite a bit of research which has found that, where women have taken antibiotics in labour because of GBS colonization, their babies have been more likely to suffer later from antibiotic-resistant bacterial infections, especially E. coli. The theory is that antibiotic-resistant E. coli has more room to flourish when GBS is depleted by antibiotics. The RCOG guideline mentions some such risks and gives refs (see page 1, section 2), but if you would like more detailed references I'd be happy to get them for you.

In the light of all this, I think that I would like to manage the situation expectantly, ie not plan to take intrapartum antibiotics unless there are other risk factors present, and to continue to plan a home birth. Would you be able to support me in this? Or is there anything else that you think I need to know about, in order to make an informed decision?

I would like to have a swab taken in late pregnancy so that I know if I am likely to have GBS colonization during labour, as obviously this could make a difference to my decisions. I do understand as well that women can test negative for GBS at different stages of pregnancy, but that babies can still be affected. However, all the research I've looked at suggests that a swab at 35-37 weeks offers the best chance of predicting whether the bacteria is likely to be present in labour.

If I did test positive for GBS at 35-37 weeks then we would of course review the situation, but I think I would be inclined to continue with expectant management unless the situation changed, eg I had PROM in labour, or baby decided to turn up at 36 weeks.

I thought it would be best to write to you as soon as I knew about the GBS result, so that you had time to think about it before we met again. I wanted to try to deal with this issue now, rather than find myself getting anxious about it.

Very best wishes...

I gave birth to my fourth lovely boy, Lachlan, at home, in a birth pool, on 7 September 2004. GBS did not cause either of us any problems - but then it would not, even without antibiotics, for at least 299 out of 300 babies in this situation. It was my easiest labour and birth thus far, but I doubt that would have been the case if I had laboured in hospital as my labour followed a sporadic course.

My personal view is that it is worth knowing that you have GBS if you do go into
premature labour, or your waters are broken for a long time while you are in
labour, because it does mean that your baby is at higher risk of problems.
That doesn't mean that you automatically 'have' to have intravenous
antibiotics in labour if you start labouring at 36 weeks, or if your waters
are broken for 18 hours while you are labouring, but it is something that
you can take into account when deciding if you want a hospital birth
and/or antibiotics.

For instance, if I were to go into labour at 35 weeks,
I would go into hospital and would probably accept IV antibiotics. If my
waters broke but there was no sign of labour within a day or so, I would
want to pay close attention to my baby's condition, and to my own
temperature, for signs of infection. But if I went into labour at term (ie
after 37 weeks) and my waters were intact and/or things were moving along
rapidly after they broke, and I didn't develop a temperature, and the
midwife was happy with the sound of my baby's heart, then I would certainly
not consider hospital birth or antibiotics.

The highest-risk period for GBS disease is the first twelve hours, and during this time any concerns about floppiness, poor colour, or difficulty breathing, should be taken very seriously.

Midwives on UK Midwifery discussion group have discussed their protocols for observing babies at risk from GBS. It appears common to have a four-hourly check on the baby's temperature, alertness, feeding and tone, usually done by a midwife.

"Most babies who are infected show symptoms within 12 hours of birth. They may be floppy and unresponsive and may not feed well. Other symptoms may include grunting, high or low temperature, fast or slow heart rates, fast or slow breathing rates, irritability, low blood pressure and low blood sugar."

Up to 90% of GBS infections occur in the first 6 days of life, usually as septicaemia with pneumonia. These “early-onset” infections are usually apparent at or soon after birth, with the following signs:

Typical symptoms of early-onset GBS infection include

grunting;

lethargy;

irritability;

poor feeding;

very high or low heart rate;

low blood pressure;

low blood sugar;

abnormal (high or low) temperature; and

abnormal (fast or slow) breathing rates with blueness of the skin due to lack of oxygen (cyanosis).

[End of quote]

The RCOG say that 90% of early-onset GBS cases present in the first 12 hours, and specifically considering the case of babies with risk factors, including a GBS positive mother who didn't have antibiotics, but where the baby appears well:

"Because 90% of cases present clinically before 12 hours of
age, the risk of disease in infants who remain well without treatment beyond this time may
not be substantially elevated above that of the infant with no risk factors. Prolonged observation
of well infants is therefore not indicated. The argument for using prophylactic treatment in well
infants is stronger in the presence of multiple risk factors but is still unproven." [RCOG 2003]

GBS disease can start later than this and can occur even at 3 months of age, although it does not appear that antibiotics in labour will affect this as the baby may be colonised from other sources within a few weeks of birth. Therefore, regardless of where the baby is born or whether IV antibiotics were given in labour, it may be useful for all parents to know about the signs of late-onset infections. Please see the GBS Support Society for information on late-onset GBS disease.

 Although universal screening and intrapartum antibiotic prophylaxis for GBS have significantly decreased the rate of early-onset disease due to this organism, the rate of late-onset GBS sepsis has remained unchanged, which is consistent with the hypothesis that late-onset disease is usually acquired from the environment.

..Late-onset GBS infection is generally not associated with perinatal risk factors or demonstrable maternal cervical colonization and may be acquired postpartum.

Antibiotics for the baby 'just in case' ?

If you are GBS positive and did not have IV antibiotics 4 hours before the baby was born, and transfer to hospital for any reason - some paediatricians will want to start your baby on antibiotics 'just in case', even if there are no signs of illness. The RCOG guidelines are that there is not enough evidence to recommend either way in this situation. However, at least one study has found a higher death rate in babies given 'precautionary' antibiotics [Benitz et al, 1999]. This review found that giving precautionary antibiotics after birth did reduce the number of babies who developed GBS disease, but increased the number who died overall (presumably from other infections as well as other illnesses):

"Universal administration of penicillin to
neonates shortly after birth (postpartum prophylaxis) reduces the
early-onset GBS attack rate by 68% but is associated with a 40%
increase in overall mortality and therefore is contraindicated."

Because it is not usual to screen for GBS in the UK, and around 30% of women are thought to carry the bacteria vaginally, it is likely that just under a third of the homebirth stories on this website are actually from GBS-positive mothers. However, very few of them will ever have been diagnosed as GBS carriers, so nobody is any the wiser!

Here are some birth stories where the mothers have, at some stage, had a positive GBS result. Note that this is not always mentioned in the birth story itself.

Lucy B decided to have intravenous antibiotics in labour after GBS was found in her urine, but went into hospital to have the drugs and then came home to have her baby. She had a rapid and positive birth, although she returned to hospital because of concerns over her baby's temperature. Baby Heidi ended up on precautionary IV antibiotics for 48 hours until a test showed that she did not have an infection.

Kate S had a great homebirth despite having Group B Strep. She had IV antibiotics in hospital, then went home to give birth. Kate is a doctor, and she found her NHS obstetrician and midwives extremely supportive.

Judith G had urinary tract infections which tested positive for Group B Strep. She planned a homebirth and had IV antibiotics at home, but transferred to hospital in early labour. For the births of her second baby, Esther, and third baby, Leah, she stayed at home.

Charlotte had a positive swab for GBS in her previous pregnancy, and went on to have a home waterbirth with a supportive NHS midwife.

Angela Hennessy had a great, straightforward home waterbirth, despite being a GBS carrier.

The Jesse Cause - links to GBS sites (www.thejessecause.org/pages/gbs_links.html) . Note that this is a US
site set up by parents of a baby who became severely ill through GBS and, as
such, articles on the site are very much in favour of preventative
antibiotics etc.. However, the links page is, obviously, full of links to
other sites with a range of information and views.